PROVIDER INFORMATION - Your Benefits At Work™ - Allegiance

PROVIDER INFORMATION

FOR THE STATE OF MONTANA EMPLOYEE BENEFIT PLAN

Table of Contents

I. State of Montana Employee Benefit Plan ? 2016 Updated Third Party Administrative (TPA) Services ? ID cards ? Verification of Benefits

II. Pre-notification III. Air Ambulance Services

? In-Network Air Ambulance Providers IV. Claim submission and payment

? Claim submission ? Sample Explanation of Benefits V. Provider Online Resources VI. Contact Information

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State of Montana Employee Benefit Plan

STATE OF MONTANA EMPLOYEE BENEFIT PLAN

? Effective January 1, 2016 the State of Montana Employee Benefit Plan (SoMT) will have new ID cards which will have a new group number: 3000900 and members will have new ID numbers

? Allegiance Provider Direct currently serves as the provider network for the (SoMT) and will continue to serve as the provider network in 2016

? Services you provide on or after January 1, 2016, will be processed by Allegiance. Payment for services you provide on or before December 31, 2015, will be processed by Cigna

? Providers will continue to submit all medical and vision claims to the Allegiance Payer ID 81040, PO Box 3018, Missoula, MT 59806-3018. For services provided prior to January 1, 2016 Allegiance will price the claim and send to Cigna for processing

? Members will receive a new health ID card in the mail prior to January 1, 2016 with updated group and identification numbers and contact information

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State of Montana Employee Benefit Plan

UPDATED ID CARDS ? EFFECTIVE 1/1/2016

? Effective January 1, 2016, Allegiance Benefit Plan Management (ABPM) will serve as the Third Party Administrator (TPA) for the SoMT

? Providers will need to update their systems with the updated information located on the patient ID cards for all services rendered on or after 1/1/2016

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State of Montana Employee Benefit Plan

VERIFICATION OF BENEFITS

? Online verification of benefits to estimate benefit levels and coverage ?

? To verify health plan specifics, contact customer service at (855) 999-1057 ? 24-hour Faxback Verification of Coverage:

(855) 999-1057 or (406) 523-3199

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State of Montana Pre-Notification

PRE-NOTIFICATION

? Utilization Management call (800) 342-6510 ? Refer to the back of the patient's ID card for specifics regarding

pre-notification

? Submit requests for elective procedures at least 72 hours before the scheduled service ? Allegiance follows MCG guidelines and Cigna Medical Policy

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State of Montana Air Ambulance

Out-of-network air ambulance transportation is very costly with most air transport companies charging 500%-1200% of what Medicare would allow for the same service. To ensure that Montana patients, family members, friends, and members of the community are not left with tens of thousands of dollars in balance billing, we need your help.

The Situation:

? When medically necessary transportation is scheduled and the patient is transported without utilizing available in-network air transport, these patients and their families are left at the mercy of out-of-network air transport companies' exorbitantly billed charges.

? Benefits will cover up to a generous amount allowed by in-network air transport, but these patients are then billed any remainder, with many owing $20,000 - $50,000 in charges after insurance has already reimbursed the provider.

The Solution:

? If you are an in-network facility and are using your in-network transport company, then payment for the member should not be an issue.

? If your flight is not available or if you do not support an air transport service, please utilize an in-network Air Ambulance provider

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State of Montana Air Ambulance

Allegiance In-Network

Phone Number

Providers

Fixed Rotary NICU Based out of:

Wing Wing Transfers

Benefis Healthcare Billings Clinic Hospital Bismark Air Medical, LLC Kalispell Regional Healthcare Montana Medical Transport NE Stat Air St. Vincent's Healthcare Valley Med Flight, Inc. American Aerovac Inc. AMR Air Ambulance

800-972-4000 800-325-1774 800-441-1310 866-302-9767 406-442-2190 800-992-7828 800-538-4357 800-828-0168 800-423-5993 800-424-7060

X

X

X

X

X

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X

X

X

X

X

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X

X

X

Great Falls, MT

X

Billings, MT

Bismark, ND

X

Kalispell, MT

Helena, MT

Glasgow, MT

X

Billings, MT

Sidney, MT & Williston, ND

For transfer any place in the US

X

For transfer any place in the US

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